UMASS Boston AT Appointment Form - Elliott Physical Therapy

UMASS AT Request Appointment Form

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This field is for validation purposes and should be left unchanged.

Student Name(Required)

DOB(Required)

Local/Intl(Required)

Local Phone #(Required)

International Phone #(Required)

Sex(Required)

Student Email(Required)

Team(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Injury Description(Required)

Please indicate if the injury is on the right side, left side, or bilateral and date of injury. If applicable, indicate date of surgery.

Referring MD(Required)

Patient must have been seen by the referring doctor for the injury being treated.

MD Phone #

(If not ________)

MD Fax #

(If not __________)

Date Last Seen by Referring MD(Required)

If not seen by a doctor yet, please set up an appointment with team doctor, __________, ASAP and indicate date of that appointment

Script Available?(Required)

Required for all cases covered by BMI and by some other insurances.

Upload Script (If you have one, *required* if BMI case)

Accepted file types: jpg, jpeg, png, heic, pdf, Max. file size: 2 GB.

Upload Imaging (If they have had any done)

Accepted file types: jpg, jpeg, png, heic, pdf, Max. file size: 2 GB.

Health Insurance Plan(Required)

Subscriber ID(Required)

Subscriber DOB(Required)

Subscriber Phone #(Required)

Parent/Guardian Name(Required)

Parent/Guardian Phone #(Required)

Upload Photo (Front of Insurance Card)(Required)

Accepted file types: jpg, jpeg, png, heic, pdf, Max. file size: 2 GB.

Upload Photo (Back of Insurance Card)(Required)

Accepted file types: jpg, jpeg, png, heic, pdf, Max. file size: 2 GB.

Covered by BMI?(Required)

If yes, a script is required

Date Case Submitted to BMI(Required)

Form Submitted By:(Required)

Date Submitted(Required)